White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Davol 5106115 Probe, 5mm x 46cm

Facility

$68.05

Hospital Charge Code	992674
Hospital Revenue Code	272
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$49.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.12
Rate for Payer: BCBS of TX Blue Advantage	$20.41
Rate for Payer: BCBS of TX Blue Essentials	$24.50
Rate for Payer: BCBS of TX PPO	$27.22
Rate for Payer: Cash Price	$46.27
Rate for Payer: Cigna Medicaid	$49.00
Rate for Payer: Molina CHIP/Medicaid	$49.00
Rate for Payer: Multiplan Auto	$44.23
Rate for Payer: Multiplan Commercial	$44.23
Rate for Payer: Multiplan Workers Comp	$44.23
Rate for Payer: Parkland Medicaid	$49.00
Rate for Payer: Scott and White EPO/PPO	$34.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.00
Rate for Payer: Superior Health Plan EPO	$9.25

Davol 5106115 Probe, 5mm x 46cm

Facility

$68.05

Hospital Charge Code	992674
Hospital Revenue Code	272
Rate for Payer: Cash Price	$46.27

DBACK PERIPH 1.50mm CL 145CM OAD US

Facility

$15,413.30

Hospital Charge Code	993878
Hospital Revenue Code	279
Rate for Payer: Cash Price	$10,481.04

DBACK PERIPH 1.50mm CL 145CM OAD US

Facility

$15,413.30

Hospital Charge Code	993878
Hospital Revenue Code	279
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

DBACK PERIPH 1.50mm SL 145cm OAD US

Facility

$15,413.30

Hospital Charge Code	993877
Hospital Revenue Code	279
Rate for Payer: Cash Price	$10,481.04

DBACK PERIPH 1.50mm SL 145cm OAD US

Facility

$15,413.30

Hospital Charge Code	993877
Hospital Revenue Code	279
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

DBM-CATHETER, EXTERNAL, FEMALE, PUREWICK

Facility

$30.32

Service Code	HCPCS C1758
Hospital Charge Code	992507
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.62

DBM-CATHETER, EXTERNAL, FEMALE, PUREWICK

Facility

$30.32

Service Code	HCPCS C1758
Hospital Charge Code	992507
Hospital Revenue Code	270
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$21.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.73
Rate for Payer: BCBS of TX Blue Advantage	$9.10
Rate for Payer: BCBS of TX Blue Essentials	$10.92
Rate for Payer: BCBS of TX PPO	$12.13
Rate for Payer: Cash Price	$20.62
Rate for Payer: Cigna Medicaid	$21.83
Rate for Payer: Molina CHIP/Medicaid	$21.83
Rate for Payer: Multiplan Auto	$19.71
Rate for Payer: Multiplan Commercial	$19.71
Rate for Payer: Multiplan Workers Comp	$19.71
Rate for Payer: Parkland Medicaid	$21.83
Rate for Payer: Scott and White EPO/PPO	$15.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.83
Rate for Payer: Superior Health Plan EPO	$4.12

DBM Cortical Fiber, 10cc

Facility

$9,006.02

Service Code	HCPCS C9359
Hospital Charge Code	992117
Hospital Revenue Code	278
Min. Negotiated Rate	$2,251.51
Max. Negotiated Rate	$4,503.01
Rate for Payer: Cash Price	$6,124.09
Rate for Payer: Cigna Commercial	$2,251.51
Rate for Payer: Multiplan Auto	$4,503.01
Rate for Payer: Multiplan Commercial	$4,503.01
Rate for Payer: Multiplan Workers Comp	$4,503.01
Rate for Payer: Scott and White EPO/PPO	$4,503.01

DBM Cortical Fiber, 10cc

Facility

$9,006.02

Service Code	HCPCS C9359
Hospital Charge Code	992117
Hospital Revenue Code	278
Min. Negotiated Rate	$810.54
Max. Negotiated Rate	$6,484.33
Rate for Payer: Amerigroup CHIP/Medicaid	$810.54
Rate for Payer: BCBS of TX Blue Advantage	$2,701.81
Rate for Payer: BCBS of TX Blue Essentials	$3,242.17
Rate for Payer: BCBS of TX PPO	$3,602.41
Rate for Payer: Cash Price	$6,124.09
Rate for Payer: Cigna Medicaid	$6,484.33
Rate for Payer: Molina CHIP/Medicaid	$6,484.33
Rate for Payer: Multiplan Auto	$4,503.01
Rate for Payer: Multiplan Commercial	$4,503.01
Rate for Payer: Multiplan Workers Comp	$4,503.01
Rate for Payer: Parkland Medicaid	$6,484.33
Rate for Payer: Scott and White EPO/PPO	$4,503.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,484.33
Rate for Payer: Superior Health Plan EPO	$1,224.82

DC001640DC001645

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	991069
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DC001640DC001645

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	991069
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DC001660

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	994016
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DC001660

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	994016
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DC003285

Facility

$4,963.25

Service Code	HCPCS C1734
Hospital Charge Code	991198
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DC003285

Facility

$4,963.25

Service Code	HCPCS C1734
Hospital Charge Code	991198
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DC032110DC032100DC003290

Facility

$4,512.00

Service Code	HCPCS C1713
Hospital Charge Code	991055
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.64
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.60
Rate for Payer: BCBS of TX Blue Essentials	$1,624.32
Rate for Payer: BCBS of TX PPO	$1,804.80
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Medicaid	$3,248.64
Rate for Payer: Molina CHIP/Medicaid	$3,248.64
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Parkland Medicaid	$3,248.64
Rate for Payer: Scott and White EPO/PPO	$2,256.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.64
Rate for Payer: Superior Health Plan EPO	$613.63

DC032110DC032100DC003290

Facility

$4,512.00

Service Code	HCPCS C1713
Hospital Charge Code	991055
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.00
Max. Negotiated Rate	$2,256.00
Rate for Payer: Cash Price	$3,068.16
Rate for Payer: Cigna Commercial	$1,128.00
Rate for Payer: Multiplan Auto	$2,256.00
Rate for Payer: Multiplan Commercial	$2,256.00
Rate for Payer: Multiplan Workers Comp	$2,256.00
Rate for Payer: Scott and White EPO/PPO	$2,256.00

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$36,067.70

Service Code	MSDRG 744
Min. Negotiated Rate	$14,536.58
Max. Negotiated Rate	$36,067.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,777.99
Rate for Payer: Amerigroup Medicare	$19,777.99
Rate for Payer: BCBS of TX Medicare	$19,777.99
Rate for Payer: Cigna Commercial	$26,392.41
Rate for Payer: Cigna Medicare	$19,777.99
Rate for Payer: Employer Direct Commercial	$19,777.99
Rate for Payer: Humana Medicare/TRICARE	$19,777.99
Rate for Payer: Molina Dual Medicare/Medicaid	$19,777.99
Rate for Payer: Molina Medicare	$19,777.99
Rate for Payer: Multiplan Auto	$36,067.70
Rate for Payer: Multiplan Commercial	$36,067.70
Rate for Payer: Multiplan Workers Comp	$36,067.70
Rate for Payer: Scott and White EPO/PPO	$16,610.12
Rate for Payer: Scott and White Medicare	$19,777.99
Rate for Payer: Superior Health Plan EPO	$19,777.99
Rate for Payer: Superior Health Plan Medicare	$19,777.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,777.99
Rate for Payer: Universal American Medicare	$19,777.99
Rate for Payer: Wellcare Medicare	$19,777.99
Rate for Payer: Wellmed Medicare	$19,777.99

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$21,865.20

Service Code	MSDRG 745
Min. Negotiated Rate	$9,196.84
Max. Negotiated Rate	$21,865.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,096.86
Rate for Payer: Amerigroup Medicare	$13,096.86
Rate for Payer: BCBS of TX Medicare	$13,096.86
Rate for Payer: Cigna Commercial	$14,651.00
Rate for Payer: Cigna Medicare	$13,096.86
Rate for Payer: Employer Direct Commercial	$13,096.86
Rate for Payer: Humana Medicare/TRICARE	$13,096.86
Rate for Payer: Molina Dual Medicare/Medicaid	$13,096.86
Rate for Payer: Molina Medicare	$13,096.86
Rate for Payer: Multiplan Auto	$21,865.20
Rate for Payer: Multiplan Commercial	$21,865.20
Rate for Payer: Multiplan Workers Comp	$21,865.20
Rate for Payer: Scott and White EPO/PPO	$10,069.50
Rate for Payer: Scott and White Medicare	$13,096.86
Rate for Payer: Superior Health Plan EPO	$13,096.86
Rate for Payer: Superior Health Plan Medicare	$13,096.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,096.86
Rate for Payer: Universal American Medicare	$13,096.86
Rate for Payer: Wellcare Medicare	$13,096.86
Rate for Payer: Wellmed Medicare	$13,096.86

D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC

Facility

$36,067.70

Service Code	MSDRG 744
Min. Negotiated Rate	$14,536.58
Max. Negotiated Rate	$36,067.70
Rate for Payer: BCBS of TX Blue Advantage	$14,536.58
Rate for Payer: BCBS of TX Blue Essentials	$17,442.21
Rate for Payer: BCBS of TX PPO	$19,380.98

D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W/O CC/MCC

Facility

$21,865.20

Service Code	MSDRG 745
Min. Negotiated Rate	$9,196.84
Max. Negotiated Rate	$21,865.20
Rate for Payer: BCBS of TX Blue Advantage	$9,196.84
Rate for Payer: BCBS of TX Blue Essentials	$11,035.14
Rate for Payer: BCBS of TX PPO	$12,261.74

D-Dimer

Facility

$449.00

Service Code	HCPCS 85379
Hospital Charge Code	1605666
Hospital Revenue Code	305
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$323.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.18
Rate for Payer: Amerigroup Medicare	$10.18
Rate for Payer: BCBS of TX Blue Advantage	$134.70
Rate for Payer: BCBS of TX Blue Essentials	$161.64
Rate for Payer: BCBS of TX Medicare	$10.18
Rate for Payer: BCBS of TX PPO	$179.60
Rate for Payer: Cash Price	$305.32
Rate for Payer: Cash Price	$305.32
Rate for Payer: Cigna Medicaid	$323.28
Rate for Payer: Cigna Medicare	$10.18
Rate for Payer: Employer Direct Commercial	$10.18
Rate for Payer: Humana Medicare/TRICARE	$10.18
Rate for Payer: Molina CHIP/Medicaid	$323.28
Rate for Payer: Molina Dual Medicare/Medicaid	$10.18
Rate for Payer: Molina Medicare	$10.18
Rate for Payer: Multiplan Auto	$291.85
Rate for Payer: Multiplan Commercial	$291.85
Rate for Payer: Multiplan Workers Comp	$291.85
Rate for Payer: Parkland Medicaid	$323.28
Rate for Payer: Scott and White EPO/PPO	$12.72
Rate for Payer: Scott and White Medicare	$10.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$323.28
Rate for Payer: Superior Health Plan EPO	$10.18
Rate for Payer: Superior Health Plan Medicare	$10.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.18
Rate for Payer: Universal American Medicare	$10.18
Rate for Payer: Wellcare Medicare	$10.18
Rate for Payer: Wellmed Medicare	$10.18

D-Dimer

Facility

$449.00

Service Code	HCPCS 85379
Hospital Charge Code	1605666
Hospital Revenue Code	305
Rate for Payer: Cash Price	$305.32

DDPB3D4 ICD COBALT DR MRI

Facility

$78,313.00

Service Code	HCPCS C1721
Hospital Charge Code	9395003
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.17
Max. Negotiated Rate	$56,385.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.17
Rate for Payer: BCBS of TX Blue Advantage	$23,493.90
Rate for Payer: BCBS of TX Blue Essentials	$28,192.68
Rate for Payer: BCBS of TX PPO	$31,325.20
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Medicaid	$56,385.36
Rate for Payer: Molina CHIP/Medicaid	$56,385.36
Rate for Payer: Multiplan Auto	$39,156.50
Rate for Payer: Multiplan Commercial	$39,156.50
Rate for Payer: Multiplan Workers Comp	$39,156.50
Rate for Payer: Parkland Medicaid	$56,385.36
Rate for Payer: Scott and White EPO/PPO	$39,156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56,385.36
Rate for Payer: Superior Health Plan EPO	$10,650.57

Know your out-of-pocket cost for care.

All Charges